Date: ___________ Date Medication Required:___________
Ship to:
Physician Patient’s Home Other __________
Respiratory Syncytial Virus
Prior Authorization Form/ Prescription
Phone: 1-888-788-4408
Fax: 1-855-554-5233
Patient Information
Last Name: First Name: Middle: DOB: ____/____/_____
Address: City: State: Zip:
Daytime Phone: Evening Phone: Sex: Male Female
Insurance Information (Attach Copies of cards)
Primary Insurance: Secondary Insurance:
ID # Group # ID # Group #
City: State: City: State:
Physician Information
Name: Specialty: NPI:
Address: City: State: Zip:
Phone # ( ) Secure Fax #: ( ) Office contact:
Primary Diagnosis
Chronic Respiratory disease arising in the perinatal period
< 24 weeks of gestation 24 weeks gestation 25-26 weeks of gestation 27-28 weeks of gestation
ICD-9/ICD-10 Code: ___________________________
Congenital Heart Disease
Congenital Abnormality of Respiratory System Cystic Fibrosis
29-30 weeks of gestation
37+ weeks of gestation
31-32 weeks of gestation
Other ____________________
33-34 weeks of gestation 35-36 weeks of gestation
Clinical Information ***** Please submit supporting clinical documentation*****
Yes No
If yes, provide NICU name and attach discharge summary:
______________________________________________________
If yes, provide date(s):
__________________ Expected date of first/next injection: ______________________
Patient’s gestational age (Required): __________ weeks ___________days
Did the patient spend time in the NICU?
Birth Weight: ________ g/kg/lbs Current Weight: ________ g/kg/lbs Date Recorded: _______________
Was this season’s first Synagis dose given in the NICU? Yes No
Patient Evaluation (Check all that apply and submit clinical documentation):
Hospitalization for RSV infection this season?
Diagnosis of hemodynamically significant Congenital Heart Disease (CHD) and < 12 months of age at start of RSV Season and patient has the following conditions (Check all that apply):
Moderate-Severe Pulmonary Hypertension
Cyanotic Heart Disease (if consulted with a pediatric cardiologist)
Acyanotic heart disease medications to control CHF (list medications): _______________ Last Date Received: _____________
AND require cardiac surgical procedures
Diagnosis of Chronic Lung Disease* and less than 12 months at start of RSV Season
*CLD is generally defined as:
Infants <32 weeks, 0 days withoxygen requirement > 21% for at least the first 28 days of birth. CLD is NOT defined as asthma, croup, recurrent upper
respiratory
infections, chronic bronchitis, bronchiolitis, or a history of a previous RSV infection
Diagnosis of Chronic Lung Disease* and between 12 to less than 24 months at start of RSV Season and receiving treatment of (check all that apply and provide last date received):
Supplemental oxygen, Date:___________________
Chronic corticosteroid therapy, Date: __________________
Diuretic therapy, Date: ___________________
Diagnosis of Cystic Fibrosis and less than 12 months of age at start of RSV season?
Clinical evidence of CLD
Nutritional compromise: Explain: ___________________________________________________
Diagnosis of Cystic Fibrosis and between 12 to less than 24 months of age at start of RSV season
Manifestations of severe lung disease (hospitalization for pulmonary exacerbation in the first year of life or abnormalities on chest radiography or CT that persists when stable)
Weight for length less than 10
th
percentile
Diagnosis of condition that impairs the ability to clear secretions from the upper airway because of ineffective cough
AND
less than 12 months at the start of RSV season
Congenital anomaly that impairs the ability to clear secretions from the upper airway because of ineffective cough
Neuromuscular condition
Please list other medical history and/or risk factors: _______________________________________________________________________________________________________________
Home Health Coordination
Please note, separate authorization is required for injection training/home health visit. Call (888) 788-4408 for prior authorization
Specialty Pharmacy to coordinate injection to coordinate injection training/home health nurse visit as necessary. Please list Agency of choice: ___________________________________
Prescription Information
MEDICATION STRENGTH DIRECTIONS QUANTITY REFILLS
Synagis 50mg 100mg
Inject 15 mg/kg IM one time per month
Epinephrine 1:1000 amp Inject 0.01 mg/kg subcutaneously as directed
Prescriber has counseled parent/guardian on Synagis therapy and the specialty pharmacy may contact parent/guardian
Physician’s Signature ________________________________________________ Date: ________________________ DAW
